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The following is a "quick and dirty" listing of the major findings in this study:
Best Practices
- Truly making the level-of-care criteria available to the public.
- Including detailed bibliographies and literature reviews.
- Basing criteria on the American Psychiatric Association's (APA) Diagnostic and Statistical Manual (DSM) IV and practice guidelines developed by the APA and the American Academy of Child and Adolescent Psychiatry.
- Updating criteria sets annually due to improvements in medical practice and/or input from the clinical community.
- Including extensive involvement of consumers, families, and advocacy organizations in the development process (through advisory boards and through feedback from appropriate organizations).
- Including extensive involvement of the clinical community in the development process.
- Having criteria covering the full continuum of care.
- Including community support services in a meaningful way.
- Including consumer-operated services in a meaningful way.
- Having distinct criteria across treatment settings for children and adolescents.
- Including detailed criteria for substance abuse versus mental health, as well as protocols for persons with co-occurring disorders.
- Embracing the concept of improving functioning and/or enhancing well being.
- Embracing the concept of the consumer's responsibility to participate in their own care.
- Embracing the concept of treatment in the least restrictive environment appropriate to meeting the consumer's needs.
- Supporting individualized treatment planning, including attention to psychosocial, occupational and cultural factors.
- Adopting an orientation of "recovery."
- Allowing the consumer's preferences among treatment options to play a role in the authorization process.
- Defining "dangerousness" comprehensively in acute admission criteria.
- Addressing the prevention of further deterioration in admission criteria.
- Using realistic definitions of "treatment settings" that are comparable to the programs in the marketplace.
- Allowing authorization of the next highest level of service when the appropriate treatment setting is not conveniently available in the community.
- Allowing authorization of the next highest level of service when the clinically appropriate treatment setting is not sensitive to the consumer's needs.
- Encouraging the development of a written agreement with the consumer when compliance is a challenge.
- Addressing the need for family support for consumers who are parents.
- Incorporating support for consumers' family members.
- Including criteria for family stabilization programs.
- Assessing whether the consumer has a family or support network in place.
- Assessing whether the family's involvement is appropriate and/or desired by the consumer.
- Including a withdrawal scale for inpatient detoxification.
- Addressing maintenance efforts to prevent relapse.
- Demonstrating an understanding that relapse during the beginning stages of treatment is common and is not treatment failure.
- Incorporating an automatic admission provision for medical detoxification for a CIWA-A score greater than or equal to 20 for consumers using multiple drugs.
- Including mobile crisis services.
- Addressing the special needs of pregnant women who have substance abuse problems.
- Including linguistic support services.
- Requiring treatment modalities to be culturally acceptable to the consumer.
- Requiring providers to have an understanding of any applicable mono-cultural, inter-faith, and/or multi-racial family dynamics.
- Having an appropriate level of provider autonomy, without care managers excessively directing care.
- Having reasonable documentation requirements for providers.
- Requiring coordination and consultation among a consumer's various providers.
- Allowing room for consultations, when appropriate.
- Providing clear language in denial notification letters with respect to the reasons for the denial and the avenues and processes for appealing the decision.
- Offering a recommendation of an alternative treatment plan when the proposed one is denied authorization.
- Offering an independent appeal option.
- Offering 4 levels of appeal.
Worst Practices
- Limiting public access to the level-of-care criteria.
- Failing to include detailed bibliographies and literature reviews.
- Failing to reference the DSM-IV and/or practice guidelines developed by the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.
- Updating criteria as infrequently as once every three years.
- Failing to involve consumers, families, and advocacy organizations sufficiently and/or meaningfully in the development process.
- Leaving gaps (to varying degrees) in the continuum of care covered.
- Failing to include community support services in a meaningful way.
- Failing to address the special considerations related to children when assessing the appropriateness of given treatment settings.
- Failing to address the needs of persons with substance abuse problems.
- Failing to address the needs of persons with co-occurring substance abuse and mental health problems.
- Ignoring the concept of improving functioning and/or enhancing well being.
- Ignoring the concept of the consumer's responsibility to participate in his/her own care.
- Failing to embrace the concept of treatment in the least restrictive environment appropriate to meeting the consumer's needs.
- Failing to support individualized treatment planning, including attention to psychosocial, occupational and cultural factors.
- Failing to adopt an orientation of "recovery."
- Failing to allow the consumer's preferences among treatment options to play a role in the authorization process.
- Over-simplifying or excessively limiting the definition of "dangerousness" included in acute admission criteria.
- Failing to address the prevention of further deterioration in admission criteria.
- "Inflating" treatment setting definitions beyond what is common in the marketplace in order to authorize providers at a lower rate of payment.
- Using a loose definition of a treatment setting to give the appearance that a certain service is included, when in reality, it is not.
- Failing to address the needs of consumers when the appropriate treatment setting is not conveniently available in the community.
- Failing to address the needs of consumers when the clinically appropriate treatment setting is not culturally sensitive to the patient's needs.
- Using lack of compliance as just cause to deny authorization.
- Failing to address the need for family support for consumers who are parents.
- Failing to address the need for support for consumers' family members.
- Failing to include criteria for family stabilization programs.
- Ignoring whether the consumer has a family or support network in place.
- Ignoring whether the family's involvement is appropriate and/or desired by the consumer.
- Failing to address maintenance efforts to prevent relapse.
- Using relapse during the beginning stages of treatment to deny further treatment.
- Excluding mobile crisis services from the criteria set.
- Failing to address the special needs of pregnant women who have substance abuse problems.
- Requiring 12-step program participation in order to access any other services related to substance abuse treatment.
- Failing to involve a child and adolescent psychiatrist in residential treatment criteria for this population.
- Failing to address the need for linguistic support services.
- Failing to ensure that the authorized treatment modalities are culturally acceptable to the consumer.
- Failing to require that providers have an understanding of any applicable mono-cultural, inter-faith, and/or multi-racial family dynamics.
- Giving care managers excessive authority to prescribe care.
- Having excessive documentation requirements for providers.
- Failing to address coordination of mental health and physical health needs.
- Failing to address the need for consultations.
- Producing denial notification correspondence that does not include clear language with respect to the reasons for the denial and the avenues and processes for appealing the decision.
- Failing to offer a recommendation of an alternative treatment plan when the proposed one is denied authorization.
- Failing to offer an independent appeal option (often a payor worst practice).
- Offering only 2 levels of appeal.
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Introduction
Key findings
"Report card" on information sharing
Methodology
Development process
Comprehensiveness
Corporate philosophy
Access issues
Compliance
Child and family issues
Substance abuse and co-occurring disorders
Cultural competence
Provider autonomy
Coordination/ consultation among providers
Denial notification and appeal processes
More observations, recommendations and areas for further study
Acknowledgments
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